2015 Pre-Authorization Requirements

Transcription

1 2015 orization Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call for complete pre-authorization guidance. You may also visit: To confirm provider participation in our network To download a pre-authorization request form To review a summary of covered benefits, limitations and exclusions To search our pre-authorization requirements by CPT/HCPC code Please fax completed pre-authorization request forms to or call (option 3). For pre-authorization of mental health/substance abuse services (in-patient or outpatient), call the Behavioral Health Care Program at Abrasion Treatment, Dermabrasion, Salabrasion Cosmetic services are not covered. Allergy Injections Ambulance s, Air Medical review required post claim submission Ambulance s (Urgent/Emergent), Ground Per Medicare guidelines, transportation home is not a covered benefit. Audiological/Audiometric See also Hearing Exams. Testing Medical Nutrition Therapy Biofeedback Biopsy, Office Setting Biopsy, Outpatient Blepharoplasty Capsule Endoscopies Cardiac Catheterization including diagnostic procedures, stent insertion, drug eluting stent, and balloon angioplasty Status change to observation requires Martin s Point Generations Advantage Plan

2 Cardiac Rehabilitation, Phase II Cataract Surgery, Outpatient Eye glass frames and lenses post-cataract surgery do not require Chemotherapy Regimen Chiropractic s Colonoscopy, Diagnostic or Routine Screening, Office or Outpatient Status change to observation requires Martin s Point Generations Advantage Plan Colorectal Screening Contact Lens Fitting Benefit is limited to patients who have had cataract surgery. CORF Comprehensive Outpatient Rehabilitation Facility Dental s Medicare-Covered s Diabetes Education and Self Management (ADEF) Diabetic Equipment and Monitoring Supplies (e.g. monitor, test strips and lancets) Diagnostic Procedures, Office or Outpatient Setting (e.g., EMG, nerve conduction, digestive endoscopy, EGD, urodynamic studies, endoscopic ultrasound) Diagnostic Tests, Office or Outpatient Setting (e.g., lab work, x-rays, MRAs, MRIs, CAT scans, PET scans, SPECT, EEG, cardiac tests) Network providers should be used for diagnostic testing whenever possible. Dialysis Treatment Durable Medical Equipment Please visit: to review our pre-authorization requirements for specific CPT/HCPCs codes.

3 Emergency Room s Eye Examinations, Non- Routine (e.g., diabetic, cataract, glaucoma) Eye Examinations Routine Status change to observation requires Any follow up services to an ER visit require PCP referral. $0 copay for Annual Routine Eye Exam Eye Glasses Benefit is limited to patients who have had cataract surgery. Foot Care, Podiatry Non- Routine (e.g. treatment of injury or trauma to foot or toes) Foot Care, Podiatry Routine (e.g. paring corns or calluses, nails, debridement) Fracture Care, Office setting Gastric Bypass and all related services beyond initial consult Hearing Exam, Diagnostic (e.g. to diagnose hearing loss) Home Health s (e.g., skilled nursing, physical therapy, occupational therapy, speech therapy) Routine foot care covered only for patients with a diabetes diagnosis. Benefit limitations apply. Pre-authorization is required for home health services rendered by out-of-network providers to members in our and plans. Hospice s Hospice benefits are covered by original Medicare. Hospital Clinic (e.g., Pain Clinic, Wound Clinic, etc.) Immunizations and Vaccinations (influenza, pneumonia, hepatitis B) Inpatient Hospital Facility Admissions IV Therapy, Home Setting Medical review required. IV Therapy, Office Setting Note that chemotherapy requires pre-authorization

4 IV Therapy, Outpatient Hospital Mammography, Medical Diagnosis Mammography Screening, Routine Annual Neuropsychological Testing Note that chemotherapy requires pre-authorization Covered every 12 months. Observation Stay Status change to inpatient admission requires additional Occupational Therapy, Office/Clinic Setting Office Visit, Primary Care Physician Yes* Yes* Yes* *No pre-authorization Office Visit, Specialist Oncology s Organ Transplants Pacemaker Checks Pap Smear Test For all women, Pap tests covered once every 24 months. If member is at high risk of cervical cancer or has had an abnormal Pap test and is of childbearing age, Pap tests covered once every 12 months. Physicals, Annual Routine Physical Therapy, Office or Clinic Setting Physician Visits Provided in Hospital Office Setting Yes* Yes* Yes* *No pre-authorization Pool Therapy Yes* Yes* Yes* *No pre-authorization Proctosigmoidoscopy Diagnostic, Office or Outpatient Hospital Setting Prostate Cancer Covered every 12 months. Screening Pulmonary Rehabilitation Radiation Therapy

5 Sigmoidoscopy, Diagnostic or Routine Screening, Office or Outpatient Hospital Setting Skilled Nursing Facility, Sub-Acute and/or Rehabilitative Facility Speech Therapy Yes* Yes* Yes* *No pre-authorization Surgery, Inpatient Surgery, Office Setting Surgery for oral, vision, plastic, cosmetic, reconstructive, or scar revision requires preauthorization. Surgery, Outpatient and Ambulatory Surgical Center Status changes to observation or inpatient admission requires separate Telemedicine Testosterone Shots Ultrasound, Diagnostic Network providers should be used for diagnostic testing whenever possible. Urgent Care Center Wheel Chair Van Revised February 2015